The difficulties diagnosing infants and children with HIV infection have been cited as barriers to increasing the number of children receiving antiretroviral therapy worldwide. Design: We implemented routine HIV antibody counseling and testing for pediatric patients hospitalized at the University Teaching Hospital, a national reference center, in Lusaka, Zambia. We also introduced HIV DNA polymerase chain reaction (PCR) testing for early infant diagnosis. METHODS: Caregivers/parents of children admitted to the hospital wards were routinely offered HIV counseling and testing for their children. HIV antibody positive (HIV+) children <18 months of age were tested with PCR for HIV DNA. RESULTS: From January 1, 2006, to June 30, 2007, among 15,670 children with unknown HIV status, 13,239 (84.5%) received counseling and 11,571 (87.4%) of those counseled were tested. Overall, 3373 (29.2%) of those tested were seropositive. Seropositivity was associated with younger age: 69.6% of those testing HIV antibody positive were <18 months of age. The proportion of counseled children who were tested increased each quarter from 76.0% in January to March 2006 to 88.2% in April to June 2007 (P < 0.001). From April 2006 to June 2007, 1276 PCR tests were done; 806 (63.2%) were positive. The rate of PCR positivity increased with age from 22% in children <6 weeks of age to 61% at 3-6 months and to 85% at 12-18 months (P < 0.001). CONCLUSIONS: Routine counseling and antibody testing of pediatric inpatients can identify large numbers of HIV-seropositive children in high prevalence settings. The high rate of HIV infection in hospitalized infants and young children also underscores the urgent need for early infant diagnostic capacity in high prevalence settings.
Equitable health services
A new trial to test the efficacy of a tuberculosis (TB) booster shot for babies is about to start in South Africa. Almost 2,800 infants will participate in the two-year trial, in which researchers from the South African Tuberculosis Vaccine Initiative (SATVI) hope to prove that a new vaccine can act as a booster shot to improve the efficacy of the only existing inoculation against TB, the Bacille Calmette-Guerin (BCG) vaccine, in use for nearly 90 years. An effective TB vaccine could help save some of the two million people who die annually from the disease, a quarter of whom are co-infected with HIV. The vaccine has been tested in HIV-infected adults in South Africa, the UK and Senegal, but because this will be the first test in infants, only HIV-negative infants will be enrolled. However, ethical issues have been raised by some about whether it is acceptable to test vaccines on poor African children.
Health systems in countries emerging from conflict are often characterised by damaged infrastructure, limited human resources, weak stewardship and a proliferation of non-governmental organisations, which all undermine health services. One response is to improve health service delivery in post-conflict countries by jointly contract non-governmental organisations to provide a Basic Package of Health Services for all the country's population. The approach is novel because it is intended as the only primary care service delivery mechanism throughout the country, with the available financial health resources primarily allocated to it. The aim is to scale up health services rapidly. This paper describes the Basic Package of Health Services contracting approach and discusses some of the potential challenges this approach may have for sexual and reproductive health services, particularly the challenges of availability and quality of services, and advocacy for these services.
This paper describes and analyses the GAVI Alliance's early experience with health systems strengthening (HSS) to improve immunisation coverage and other maternal-child health outcomes. The challenges have been forging a common vision and approach, governance, balancing pressure to move money with incremental learning, managing partner roles and relationships, managing the ‘value for money’ risk, and capacity building. This mid-point stock-taking makes recommendations for moving GAVI forward in a thoughtful manner. The findings should be of interest to other global health partnerships because of their larger significance. This is a story about how a successful alliance that decided to broaden its mandate has responded to the technical, organisational, and political complexities that challenge its traditional business model.
Understanding urban black women's health care practices will enable health promoters to develop interventions that are successful. The problem investigated here was to gain an understanding of the health care practices of urban black women that could influence health promotion activities. The design was qualitative and exploratory. The sampling method was convenient and purposive, and the sample size was determined by saturation of the data. Data was gathered through semi-structured interviews using six specific themes and the analysed using open coding. The results indicated that the social environment created by the registered nurses in the primary health influenced the health care practices of the women negatively. Practices regarding the seriousness of a health problem suggest a possible reason may exist for late admission of a person with a serious health problem.
The objective of this paper was to measure the extent and causes of inequalities in the ownership and utilisation of bed nets (ITNs) across socioeconomic groups (SEGs) and age groups in Tanga District, north-eastern Tanzania. A questionnaire was administered to heads of 1,603 households from rural and urban areas and focus group discussions were used to explore community perspectives on the causes of inequalities. Use of ITNs remained appallingly low compared to the RBM target of 80% coverage. The results highlight the need for mass distribution of free ITNs, a community-wide programme to treat all untreated nets and to promote the use of long-lasting insecticidal nets (LLINs) or longer-lasting treatment of nets, targeting the rural population and under-fives.
This paper describes the immediate impact of conflict following Kenya’s presidential elections on 27 December 2007 with regard to clinic attendance and medication adherence for HIV-infected children cared for within the USAID-Academic Model Providing Access to Healthcare (AMPATH) in western Kenya. The researchers conducted a mixed methods analysis that included a retrospective cohort analysis, as well as key informant interviews with pediatric healthcare providers. They found that, during this period of humanitarian crisis, the vulnerable, HIV-infected paediatric population had disruptions in clinical care and in medication adherence, putting children at risk for viral resistance and increased morbidity. However, unique programme strengths may have minimised these disruptions.
This article discusses health sector reform experiences of four developing countries, including Tanzania, and identifies the lessons learned. Findings suggest that decentralisation works effectively while implementing primary and secondary health programmes. Decentralisation of power and authority to local authorities requires strengthening and supporting these units. Community participation facilitates recruitment and development of field workers, facility improvement and service delivery. For providing financial protection to the poor, there is a need to review user fees and develop affordable health insurance with an exemption mechanism. There is no uniform health sector reform approach for all countries – policy makers must examine the context and determine the reform measures that constitute the best means in terms of equity, efficiency and sustainability.
New Health Minister, Dr Aaron Motsoaledi has announced five key priorities for action, one of which is to strengthen the quality of care in the health service. To succeed in boosting service delivery, the new Health Minister identified four key areas he will be giving his immediate attention in the next few weeks: the official launch the prevention of mother-to-child HIV transmission acceleration plan, a new team that will deal with norms and standards between national, provincial and district health systems, a future meeting of provincial health MECs to come up with cost-containment measures or austerity measures to curb over-spending, and a consultation with his counterparts within the Inter-Ministerial Committee to speedily resolve the issues around the occupational-specific dispensation. But Motsoaledi was thin on detail about how he plans to address the issues.
This study sought to assess progress in South Africa with respect to deinstitutionalisation and the integration of mental health into primary health care, with a view to understanding the resource implications of these processes at district level. A situational analysis in one district site, typical of rural areas in South Africa, was conducted, based on qualitative interviews with key stakeholders and the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS). The decentralisation process remains largely limited to emergency management of psychiatric patients and ongoing psychopharmacological care of patients with stabilised chronic conditions. Similar to other low- to middle-income countries, deinstitutionalisation and comprehensive integrated mental health care in South Africa is hampered by a lack of resources for mental health care within the primary health care resource package, as well as the inefficient use of existing mental health resources.